Abstract
BackgroundMalaria is a leading cause of morbidity and mortality among HIV-infected pregnant women in sub-Saharan Africa: at least 1 million pregnancies among HIV-infected women are complicated by co-infection with malaria annually, leading to increased risk of premature delivery, severe anaemia, delivery of low birth weight infants, and maternal death. Current guidelines recommend either daily cotrimoxazole (CTX) or intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) for HIV-infected pregnant women to prevent malaria and its complications. The cost-effectiveness of CTX compared to IPTp-SP among HIV-infected pregnant women was assessed.MethodsA microsimulation model of malaria and HIV among pregnant women in five malaria-endemic countries in sub-Saharan Africa was constructed. Four strategies were compared: (1) 2-dose IPTp-SP at current IPTp-SP coverage of the country (“2-IPT Low”); (2) 3-dose IPTp-SP at current coverage (“3-IPT Low”); (3) 3-dose IPTp-SP at the same coverage as antiretroviral therapy (ART) in the country (“3-IPT High”); and (4) daily CTX at ART coverage. Outcomes measured include maternal malaria, anaemia, low birth weight (LBW), and disability-adjusted life years (DALYs). Sensitivity analyses assessed the effect of adherence to CTX.ResultsCompared with the 2-IPT Low Strategy, women receiving CTX had 22.5% fewer LBW infants (95% CI 22.3–22.7), 13.5% fewer anaemia cases (95% CI 13.4–13.5), and 13.6% fewer maternal malaria cases (95% CI 13.6–13.7). In all simulated countries, CTX was the preferred strategy, with incremental cost-effectiveness ratios ranging from cost-saving to $3.9 per DALY averted from a societal perspective. CTX was less effective than the 3-IPT High Strategy when more than 18% of women stopped taking CTX during the pregnancy.ConclusionIn malarious regions of sub-Saharan Africa, daily CTX for HIV-infected pregnant women regardless of CD4 cell count is cost-effective compared with 3-dose IPTp-SP as long as more than 82% of women adhere to daily dosing.
Highlights
Malaria is a leading cause of morbidity and mortality among HIV-infected pregnant women in subSaharan Africa: at least 1 million pregnancies among HIV-infected women are complicated by co-infection with malaria annually, leading to increased risk of premature delivery, severe anaemia, delivery of low birth weight infants, and maternal death
Each woman was characterized by CD4 cell count, antiretroviral therapy (ART) status, and malaria preventive treatment status
Compared to the Reference Strategy, the CTX Strategy reduced incidence of low birth weight (LBW) by 6.8% to 28.7%, anaemia by 9.8% to 14.5%, and malaria parasitaemia by 9.0% to 15.5% across the five countries
Summary
Malaria is a leading cause of morbidity and mortality among HIV-infected pregnant women in subSaharan Africa: at least 1 million pregnancies among HIV-infected women are complicated by co-infection with malaria annually, leading to increased risk of premature delivery, severe anaemia, delivery of low birth weight infants, and maternal death. Previous guidelines recommended 3 doses of intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTpSP) for HIV-infected pregnant women with CD4 > 350 cells/mm or daily cotrimoxazole (CTX) for women with CD4 < 350 cells/mm3 [10] Despite these guidelines, median coverage rate of receiving at least 1 dose of IPTpSP from antenatal clinics in sub-Saharan Africa is 19.0%, which remains markedly lower than the international targets, despite high rates of antenatal clinic attendance (75% of women in sub-Saharan Africa attend at least twice) [11, 12]. In analyses of the low coverage of IPTpSP in sub-Saharan Africa, information barriers (unclear guidelines and uncertain messages about timing of IPTpSP in pregnancy), behavioral barriers (irregular antenatal clinic visits), and system barriers [sulfadoxine–pyrimethamine (SP) stockouts and low clinic staffing] emerge as salient [13,14,15,16,17,18]
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